A Benefit-Risk Conceptual Framework for Biologic Use During Pregnancy: A Mini-Review

Recent reports related to in utero exposure of marketed immunosuppressive biologics led to clinical recommendations to delay live vaccinations for infants due to the concern of reduced vaccine effectiveness and/or increased risk of vaccine-related disease. These delays can increase the risk of children contracting vaccine preventable diseases, yet the alternative cessation of biologics during pregnancy may result in increased autoimmune disease activity for the pregnant person, raising complex benefit-risk (B-R) considerations and trade-offs. Our goal is to develop a conceptual framework for B-R assessment based on the key benefits and risks pregnant people would consider for themselves and their children when continuing (vs. discontinuing) a biologic during pregnancy. The proposed framework defines the decision contexts, key domains and attributes for potential benefits, and risks of biologic use during pregnancy, informed by a literature review of indications for biologics and refined with key clinical stakeholders. The framework includes both the pregnant person taking the biologic and the infant potentially exposed to the biologic in utero, with potential benefit and risk domains and attributes for each participant. To advance this conceptual framework, there are considerations of potential biases and uncertainty of available data that will be imperative to address when quantifying the B-R framework. For these reasons, we recommend the formation of a consortium to ensure development of a robust, validated framework that can be adopted in the healthcare setting.

Opioid use surrounding diagnosis and follow-up in patients with ankylosing spondylitis, psoriatic arthritis, and rheumatoid arthritis: Results from US claims databases

OBJECTIVE

To describe patients' use of opioids in the year preceding and year following new diagnosis of ankylosing spondylitis (AS), psoriatic arthritis (PsA), or rheumatoid arthritis (RA), compared with patients without the/se diseases.

METHODS

This study used US IBM® MarketScan® Commercial Claims and Encounters (CCAE) and Medicaid data and included three cohorts, comprised of incident cases of AS, PsA, or RA (2010-2017). Three matched comparator patients (without the incident disease) were selected for each patient within the disease cohort. Opioid use and appropriate treatment exposure (as defined by US guideline recommendations) in the 12-month baseline and follow-up periods were evaluated using descriptive analyses.

RESULTS

Prevalence of claims for opioids was higher for disease cohorts vs. comparators in CCAE; 36.4% of patients with AS, 29.5% with PsA, and 44.4% with RA did not have any claim for guideline-appropriate therapy in follow-up. Prevalence of claims for opioids was also higher for disease cohorts vs. comparators in Medicaid; 30.6% of patients with AS, 36.6% with PsA, and 65.4% with RA did not have any claim for guideline-appropriate therapy in follow-up.

CONCLUSIONS

In patients with AS, PsA, or RA, there was high reliance on opioids at and around the time of diagnosis. Significant proportions of patients were not on appropriate treatment as defined by professional society post-diagnosis guidelines; this discordance between actual patient therapies and treatment recommendations may suggest a need for better awareness of appropriate pain management and treatment strategies in rheumatic diseases. Key Points • This study analysed opioid use among patients with ankylosing spondylitis (AS), psoriatic arthritis (PsA), or rheumatoid arthritis (RA), and adds to current knowledge by expanding beyond assessment of opioid use at diagnosis, to the year before and after diagnosis. • Opioid use was found to be highly prevalent in AS, PsA, and RA in the year prior to diagnosis and, interestingly, was still seen during the year after diagnosis. • Opioids are neither disease modifying, nor a targeted/recommended treatment for chronic autoimmune diseases. In addition to their association with significant economic costs, opioids are potentially hazardous and are not better than alternative treatments with superior safety profiles. • The reasons behind opioid prescribing patterns should be explored further to support movement to targeted therapies.

A large outbreak of the Kappa mutation of COVID-19 in Cork, Ireland, April-May 2021

BACKGROUND

In May 2021, the B.1.617 variant of SARS-CoV-2 emerged in Ireland, and both Delta and Kappa sub-lineages were initially deemed variants of concern (VOCs) on a precautionary basis. We describe a large outbreak of SARS-CoV-2 B.1.617.1 (Kappa mutation) linked to a private gathering among third level students in Cork, Ireland.

METHODS

Surveillance data were available from the Health Service Executive COVID Care Tracker. The epidemiological sequence of infection for each new case in this outbreak was tracked and whole genome sequencing was requested on all linked cases. Enhanced public health control measures were implemented by the Department of Public Health HSE-South to contain onward spread of VOCs, including retrospective contact tracing, lengthy isolation and quarantine periods for cases and close contacts. Extensive surveillance efforts were used to describe and control onward transmission.

RESULTS

There were 146 confirmed SARS-CoV-2 cases linked to the outbreak. All sequenced cases (53/146; 36%) confirmed Kappa mutation. The median age was 21 years (range 17-65). The majority (88%) had symptoms of SARS-CoV-2 infection. There were 407 close contacts; the median was 3 per case (range 0-14). There were no known hospitalisations, ICU admissions or deaths. Vaccination data was unavailable, but the outbreak pre-dated routine availability of COVID-19 vaccines among younger adults in Ireland.

CONCLUSION

Enhanced public health control measures for new and emerging variants of SARS-CoV-2 may be burdensome for cases and close contacts. The overall public health benefit of enhanced controls may only become apparent when evidence on disease transmissibility and severity becomes more complete.

Residual Disease Associated with Suboptimal Treatment Response in Patients with Psoriatic Arthritis: A Systematic Review of Real-World Evidence

Objective

This systematic literature review aimed to identify and summarise real-world observational studies reporting the type, prevalence and/or severity of residual symptoms and disease in adults with psoriatic arthritis (PsA) who have received treatment and been assessed against remission or low disease activity targets.

Methods

Patients had received treatment and been assessed with treat-to-target metrics, including minimal disease activity (MDA), Disease Activity Index in PsA (DAPSA) and others. MEDLINE, Embase® and the Cochrane Database of Systematic Reviews (CDSR) were searched using search terms for PsA, treatment targets and observational studies. Screening of search results was completed by two independent reviewers; studies were included if they reported relevant residual disease outcomes in adults with PsA who had received one or more pharmacological treatments for PsA in a real-world setting. Non-observational studies were excluded. Information from included studies was extracted into a prespecified grid by a single reviewer and checked by a second reviewer.

Results

Database searching yielded 2328 articles, of which 42 publications (27 unique studies) were included in this systematic literature review. Twenty-three studies reported outcomes for MDA-assessed patients, and 14 studies reported outcomes for DAPSA-assessed patients. Physician- and patient-reported residual disease was less frequent and/or severe in patients reaching targets, but often not absent, including when patients achieved very low disease activity (VLDA) or remission. For example, studies reported that 0–8% patients in remission according to DAPSA (or clinical DAPSA) had > 1 tender joint, 25–39% had Psoriasis Area and Severity Index (PASI) score > 1 and 0–10% had patient-reported pain > 15. Residual disease was usually less frequent and/or severe among patients achieving MDA-assessed targets versus DAPSA-­assessed targets, especially for skin outcomes.

Conclusion

The findings demonstrate a need for further optimisation of care for patients with PsA.

Occurrence of Possible Rheumatologic Immune-Related Adverse Events (rh-irAEs) Associated with Immune Checkpoint Inhibitor (ICI) Therapy

Introduction

Current epidemiologic literature of rheumatologic immune-related adverse events (rh-irAEs) consists of clinical trials, case reports, or smaller, single-center series. We evaluate the occurrence of rh-irAEs during immune checkpoint inhibitor (ICI) therapy from US commercial claims data.

Methods

Patients newly initiating ICI therapy in commercial claims data were eligible for inclusion. Rh-irAEs were defined using ≥ 1 International Classification of Diseases (ICD)-9 or ICD-10-Clinical Modification (CM) claims for selected events, ranging from joint pain and myalgia to ankylosing spondylitis and psoriasis. The percentage of patients experiencing rh-irAEs after ICI initiation was determined.

Results

A total of 5722 patients initiating an ICI between January 1, 2012, and June 30, 2018, were included; 201 patients (3.5%) had a history of rheumatic disease. Among the 5521 patients without a history of rheumatic disease, 29.6% experienced ≥ 1 rh-irAE in follow-up, decreasing to 22.6% when assessing events for which there was no diagnostic history. Limiting to claims for rh-irAE with a rheumatologist provider, the proportion of patients experiencing an event decreased to 0.9%. Among patients with a history of rheumatic disease, 71.6% experienced ≥ 1 rh-irAE. Limiting to events for which the patient did not have a history during baseline, 35.3% experienced an event.

Conclusions

Occurrence of rh-irAEs during ICI use is higher in patients with pre-existing rheumatic disease compared to those with no pre-existing rheumatic disease. However, the most common events were not definitive rheumatic diseases but rather symptoms, such as pain in joints. Occurrence of events associated with a rheumatologist provider was substantially lower, suggesting that either patients are not referred to a rheumatologist or referral does not result in confirmation of the diagnosis by the rheumatologist.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00359-z.

Epidemiology and Treatment of Patients with Rheumatoid Arthritis, Psoriatic Arthritis and Psoriasis in Germany: A Real-World Evidence Study

Introduction

Rheumatoid arthritis (RA), psoriatic arthritis (PsA) and psoriasis (PSO) are chronic inflammatory diseases that have a substantial impact on patients’ health. This retrospective database study aimed to assess the epidemiology, comorbidities, diagnosis and treatment patterns of RA, PsA and PSO in the German population.

Methods

Data were extracted from the Deutsche Forschungsdatenbank für Abrechnungsinformationen der Krankenversicherung database from 2012 to 2016 for patients aged ≥ 18 years holding full health coverage in the reporting year at least. Diagnoses were defined according to International Classification of Diseases (ICD)-10 codes. Reported outcomes included prevalence and incidence rates, pre-defined comorbidities, diagnosing and treating physicians, and treatment exposure. A subgroup analysis was performed for women of childbearing age (females aged 18–45 years).

Results

The prevalence rates of RA, PsA and PSO in Germany were consistent over the study period; by 2016 they were 0.4%, 0.3% and 2.1%, respectively, and in women of childbearing age they were 0.2%, 0.2% and 1.5%, respectively. RA, PsA and PSO were predominantly observed among patients aged > 45 years. RA and PsA were more prevalent in women, while PSO had an approximately equal gender distribution. Depressive episodes were the most frequently reported comorbidity in 2016 (RA: 25.7%; PsA: 25.1%; PSO: 17.8%), and this was similar in women of childbearing age (RA: 20.5%; PsA: 23.4%; PSO: 16.3%). Approximately 50% of patients with RA and PsA and 6% of patients with PSO were receiving systemic treatment in 2016, of which methotrexate (RA: 38.4%; PsA: 30.2%; PSO: 2.2%) was most common. Biologic therapies were the least frequently used treatment options (RA: 28.9%; PsA: 20.9%; PSO: 1.8%).

Conclusions

This analysis provides key epidemiological information for patients with RA, PsA and PSO, including in women of childbearing age, in Germany and highlights common comorbidities and that patients were likely receiving insufficient treatment for these diagnoses.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-020-01522-8) contains supplementary material, which is available to authorized users.

Opioid Use in Patients with Ankylosing Spondylitis Is Common in the United States: Outcomes of a Retrospective Cohort Study

OBJECTIVE

To assess the prevalence of chronic opioid use in patients with ankylosing spondylitis (AS), and to compare the characteristics of patients with and without chronic opioid use.

METHODS

This was a retrospective cohort study of patients with AS identified in the Truven Health MarketScan Research database between January 1, 2012, and March 31, 2017. Commercial and Medicaid claims data were examined using both specific (720.0 and M45.x) and broader (720.x and M45.x) International Classification of Diseases (ICD) coding definitions. Patients were aged ≥ 18 years on the date of first qualifying ICD code occurrence (the index date). Demographics and clinical characteristics were assessed in the 12-month period preceding the index date. The 12-month followup period was used to assess prevalence and characteristics of chronic opioid use.

RESULTS

Chronic opioid use was common among patients with commercial claims (23.5% of ICD 720.0 patients; 27.3% of ICD 720.x patients), and especially those with Medicaid claims (57.1% and 76.7%, respectively). The proportion of patients with claims for anti-tumor necrosis factor therapies during followup was often low, and for Medicaid patients was lower among those with chronic opioid use (29.6% of ICD 720.0 patients; 2.3% of ICD 720.x patients) than those without (47.1% and 7.1%, respectively). Among chronic opioid users in all cohorts, the cumulative supply of opioids was typically high (≥ 270 days in the followup period); most opioids prescribed were Schedule II.

CONCLUSION

Patients with AS receive opioids with disturbing frequency. The infrequent prescription of recommended therapies to these patients reflects a need to optimize treatment further through education of patients and healthcare professionals alike.

Assessing Collaboration in a National Research Partnership in Quality Improvement in Indigenous Primary Health Care: A Network Approach

Background: The ABCD National Research Partnership was formed in mid-2010 as a collaboration to harness the expertise, experiences and resources of Aboriginal and Torres Strait Islander community-controlled peak bodies, government and research organisations to improve the quality of Indigenous primary health care. The aim of this study was to apply social network methods to assess collaboration and functioning of the Partnership at two time-points.

Methods: A social network analysis (SNA) survey was conducted in early 2013, with a follow-up survey in mid-2014. In the two survey rounds, online surveys were emailed to one senior person of the organisation participating in the Partnership (2013: 14 organisations; 2014: 11 organisations). The surveys collected data on respondent perceptions of the Partnership as well as social network relationship data. Social network methods were used to apply standardised metrics to assess how well the partnership was functioning as a collaborative three years into its operation, and in its fourth year.

Results: Most respondents rated the Partnership as successful in progressing toward its goals. Network density and centrality scores show a well-connected partnership spanning different organisational types and states/territories (Northern Territory, Queensland, Western Australia, South Australia, and Far-West New South Wales). High centrality scores reflect high connectivity between key hubs in the network, contributing toward the shared goal of improved Indigenous primary health care. Network diagrams show key structural positions by organisational type, the frequency and intensity of interactions and the strengths and potential vulnerabilities in the partnership network, with comparisons at two time points for the partnership.

Conclusions: The study found that the Partnership was effective in securing collaboration across its partners. Partners' contribution of resources reflected their active involvement. There was a high level of agreement on the achievement of the key goals of the Partnership, showing shared sense-making amongst partners. SNA tools assisted with monitoring the network over time to develop strategies supporting connections between partners for sustaining collaborative learning. Study findings identify successful approaches for a research partnership to improve quality of care in Indigenous primary health care and provide encouragement for wider applications for research partnerships and collaborations in Australia and internationally.

Norovirus in Transplantation

Noroviruses are among the most common cause of diarrhea in transplant recipients. The clinical spectrum of norovirus infection after transplant is increasingly being recognized. As substantial morbidity is now associated with norovirus infections in this population; the quest for rapid diagnostic modalities and newer therapies has expanded. Transplant recipients with norovirus infection are at risk for several complications, including protracted illness with malnutrition, organ failure, and chronic viral shedding. This review summarizes the current knowledge on the epidemiology, complications, diagnosis, and treatment of norovirus infection in the transplant setting.

Control of norovirus outbreak on a pediatric oncology unit

BACKGROUND

Patients undergoing treatment for cancer with chemotherapy and hematopoietic stem cell recipients are at risk for severe morbidity caused by norovirus (NV).

METHODS

We describe a NV outbreak on the Memorial Sloan Kettering Cancer Center's pediatric oncology unit. Stool testing for diagnosis of NV was performed by real-time polymerase chain reaction (PCR).

RESULTS

Twelve NV cases occurred; 7 were hospital acquired. Twenty-five health care workers reported NV compatible illness. Patient-to-patient transmission occurred once. The practices of the Centers for Disease Control and Prevention were supplemented with electronic surveillance, surrogate screening for NV, and heightened cleaning. Two additional cases occurred after implementation of interventions. Long-term shedding was detected in 2 patients.

CONCLUSION

We describe interventions for controlling NV on a pediatric oncology unit. High-risk chronic shedders pose ongoing transmission risks. PCR is a valuable diagnostic tool but may be overly sensitive. Surrogate markers to assess NV burden in stool and studies on NV screening are needed to develop guidelines for high-risk chronic shedders.

Clostridium difficile infection after allogeneic hematopoietic stem cell transplant: strain diversity and outcomes associated with NAP1/027

Allogeneic hematopoietic stem cell transplantation (HSCT) recipients are at high risk for developing Clostridium difficile infection (CDI). We studied the incidence, risk factors, NAP1/027 prevalence, and clinical outcomes, including acute lower gastrointestinal graft-versus-host disease (GI GVHD), associated with early CDI in this population. A retrospective review was conducted of patients who underwent allogeneic HSCT at Memorial Sloan Kettering Cancer Center from January 1, 2005 to September 30, 2010. Early CDI was defined as infection occurring from day -10 to day +40 from stem cell infusion. Among 793 patients who received allogeneic HSCTs, early CDI occurred in 11.9%; 56% cases were between day -5 and day +5. Overall incidence was 25.2 cases/10,000 at-risk days. There was a high prevalence of NAP1/027 strains during peak incidence (61% in 2008). NAP1/027 was the most common strain in both adult and pediatric cases (24% and 23%, respectively). CDI was clinically mild, including those due to NAP1/027. Metronidazole was the primary treatment for 91 of 94 patients, 7 of 8 cases refractory to metronidazole had no response to vancomycin, and none was due to NAP1/027. Relapse of CDI was common (31%). The cumulative incidence of GI GVHD in patients with and without early CDI was 6.8% and 8%, respectively (P = .5). Most cases of CDI occurred during conditioning or immediately after transplant. Despite high prevalence of NAP1/027, we found only mild disease. Most patients were treated successfully with metronidazole, irrespective of NAP1/027 status. There was no significant association between early CDI and subsequent development of GI GVHD. This study demonstrates the high incidence of CDI early after allogeneic HSCT with wide diversity among infecting strains. Despite the high prevalence of NAP1/027, the disease is mild but relapses are common. No association was found between CDI and subsequent development of GI GVHD.

Carbapenemase-producing Enterobacteriaceae in Irish critical care units: results of a pilot prevalence survey, June 2011

The epidemiology of carbapenemase-producing Enterobacteriaceae (CPE) in Ireland is changing, with an increase in the number of reported cases in late 2010 and early 2011. Reported cases were predominantly linked to critical care units. In June 2011, a four-week national pilot survey took place in 40 Irish critical care units (37 adult and three paediatric) to examine the prevalence of rectal carriage of CPE and inform national CPE screening guidelines. A total of 760 screening swabs were taken over the study period, and CPE were not detected in any of the participating critical care units.